There was plenty to blame: the car wreck that broke his back. The job pouring concrete that shattered his spine a second time. The way he tore up his insides with cigarettes, booze, cocaine, and opioids.

It all amounted to this: Carl White was in pain. All the time. And nothing helped — not the multiple surgeries, nor the self-medication, not the wife and daughter who supported him and relied on him.

Then White enrolled in a pain management clinic that taught him some of his physical torment was in his head — and he could train his brain to control it. It’s a philosophy that dates back decades, to the 1970s or even earlier. It fell out of vogue when new generations of potent pain pills came on the market; they were cheaper, worked faster, felt more modern.

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But the opioid epidemic has soured many patients and doctors on the quick fix. And interest is again surging in a treatment method called biopsychosocial pain management, which trains patients to manage chronic pain with tools ranging from physical therapy to biofeedback to meditation. It helped Carl White, a 43-year-old social worker from Leroy, Minn.

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The catch? It can take weeks and cost tens of thousands of dollars — and thus remains out of reach for most patients with chronic pain.

“We’ve been banging our heads on the wall, and banging our fists on the door, trying to get insurers to pay for this,” said Dr. Bob Twillman, executive director for the Academy of Integrative Pain Management. “For the most part, they will not.”

When pain is not just physical

Chronic pain affects nearly 50 million Americans, according to the American Pain Foundation. The largest drivers include migraines, arthritis, and nerve damage — but in many cases, emotional trauma also contributes to the sense of misery.

“We have a lot of people in this country who are unhappy, isolated, and hurting,” said Jeannie Sperry, a psychologist who co-chairs the division of addictions, transplant, and pain at Mayo Clinic. “Depression hurts. Anxiety hurts. It’s rare for people to have chronic pain without one of these co-morbidities.”

Indeed, chronic pain has a substantial psychological element: Being in pain often leads to self-imposed isolation. That loss of a social network then leads to anxiety, depression, and a tendency to catastrophize the pain — so that it’s all a patient can think about.

So even if the initial cause of the pain is treated medically — with opioids, surgery, steroid injections, or physical therapy — it’s unlikely to go away entirely. That may be why just 58 percent of patients who routinely take prescription painkillers say the drugs are effective in managing their chronic pain, according to the American Academy of Pain Medicine.

“In the past, pain was viewed just as a physical issue,” said Robert Gatchel, a pain management researcher and professor at University of Texas, Arlington. “The thought was, if you cut something out, the pain will go away — but lo and behold, it doesn’t in many cases, and sometimes [the pain] gets worse.”

“In the past, pain was viewed just as a physical issue. The thought was, if you cut something out, the pain will go away — but lo and behold, it doesn’t in many cases …”

Robert Gatchel, University of Texas at Arlington

Acute pain is generated in the peripheral nervous system, which conducts danger signals to the brain. From there, the brain determines whether it’ll experience the pain signals or ignore them, Sperry said. “In the case of chronic pain, that system has gone awry,” Sperry said. “Without training your brain to turn down the alarm system, the alarm keeps going off all the time.”

So although the pain may have originated in the foot, patients end up with headaches, chronic nausea, chronic fatigue, and back pain — developing a host of other symptoms as the brain short-circuits.

“Focusing solely on a pain generator in the body,” like a herniated disc or nerve damage, “utterly and completely misses the chronic, complex, changing nature of chronic pain” as it’s processed and experienced in the brain over time, said Dr. Tracy Jackson, an associate professor of anesthesiology and a pain specialist at Vanderbilt University.

Hardware removed from Carl White’s body after his last surgery.Sarah Stacke for STAT

Bracing for ‘New Age-y nonsense’

The second time White broke his back, he decided to shift gears: He left the cement pouring business and got first his high school diploma, and then a college degree. He began working at Mayo Clinic as a neurosurgery coordinator — but still relied on alcohol and painkillers to get through the day.

It’s tough to estimate how many people with chronic pain develop a dependence on medications, but in 2014, about 2.5 million adults had opioid addictions — and many of those addictions started with a prescription for potent pain pills.

White soon found that unless he distracted himself with intense physical labor, he focused obsessively on the pain, and his thoughts spiraled into darkness. “If it’s a 1-to-10 pain scale, a chronic pain patient will say, ‘Mine’s at a 12 or 13,’” White said. “A 1-to-10 scale isn’t even sufficient. When I was at my worst, all I know is that my pain was on my mind 24/7.”

“A 1-to-10 scale isn’t even sufficient. When I was at my worst, all I know is that my pain was on my mind 24/7.”

Carl White, social worker

By then, White had run out of medical options. No one would operate on him, and the pills were making him feel worse, not better. Finally, in 2009, Mayo referred him to its pain management clinic.

White went in with a great deal of skepticism. He recalls sitting in the back of the meeting room, arms crossed, waiting for the pain rehabilitation specialists to tell him some “New Age-y nonsense.”

Instead, in that short, intensive program, White learned tools that worked for him — some of them very simple instructions, like how to lift heavy objects with his legs instead of his back. The program also helped him process some traumas from his childhood, White said, such as when he was orphaned at age 10 when he found his abusive, alcoholic father dead.

The psychological component also helped White learn to be kinder to himself — easing a great deal of self-imposed pressure to overexert himself.

These days, White’s baseline pain stays at a 4 — meaning, it’s always there, but it’s manageable. On the bad days, he considers small things, like getting out of bed in the morning, to be victories. “Instead of lying in bed, I gotta get my butt out of bed — otherwise it becomes a tomb, and the ‘stinkin’ thinkin’’ comes back,” White said.

He’s now working at the Minnesota Adult and Teen Challenge, a faith-based addiction therapy program in Rochester. And he’s working on launching a pain management program for his clients.

White and a client practice diaphragmatic breathing and passive muscle relaxation as a way to manage pain.Sarah Stacke for STAT

Plumbing psychology to deal with pain

There used to be hundreds of integrated pain management centers all across the country. But in the ’90s, the insurance market shifted; more patients joined managed care plans that limited them to a narrow network of doctors. Then in 1996, the powerful opioid OxyContin hit the market. It quickly became the tool of choice for controlling pain.

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The Mayo Clinic’s outpatient pain program runs for three weeks, and keeps patients busy from 8 a.m. and 5 p.m.

They do physical and occupational therapy — learning, for instance, how to go shopping or do yard work in ways that won’t aggregate their pain. And the program includes four to five hours of lessons each day on how to understand pain. Patients learn to relax, breathe slowly, and meditate to mitigate some of the anxiety-related pain flare-ups. Entire sessions are dedicated to understanding the psychological underpinnings of their own pain.

“By the time people get here, they have a lot of functional disability,” said Sperry, who helps run the program. “They’re fearful, because they’re getting such strong signals in the brain — so we offer a very structured increase in activity, where we’re retraining the brain to soothe the central nervous system to not process these signals as danger.”

The program is not cheap. It costs $37,000 to $42,000 for three weeks. Gatchel, who is affiliated with several pain management programs in Texas, said that price is an “exception to the norm,” and less intense versions of the treatment can run between $4,000 and $10,000.

“We have a lot of people in this country who are unhappy, isolated, and hurting. Depression hurts. Anxiety hurts.”

Jeannie Sperry, Mayo Clinic

Studies suggest the programs can be quite effective. The Brooks Rehabilitation pain program in Jacksonville, Fla., reports that six months after intensive treatment, 9 out of 10 patients reported improvements in quality of life and 3 out of 4 felt decreased levels of pain. The center reported that just 6 percent of patients who were weaned off of opioids during the program resumed taking them afterwards.

Another study, published in the journal Pain, followed 339 patients who completed a three-week program at the Mayo Clinic Pain Rehabilitation Center. Some 70 percent responded to questionnaires six months after their treatment, and reported significant improvements in pain severity, depression, social functioning, and other metrics. The gains held both for patients who had been taking opioids before entering the center and for those who had not.

A renewed interest in alternative treatments

Such results, and anecdotal reports from patients like White, have spurred renewed interest in biopsychosocial pain management.

Insurance coverage is still a battle: Many plans will pay for medical treatments such as surgeries, pills, and steroid injections that can run $2,000 apiece. They’re not as keen to cover therapy, massage, and meditation. “It’s much more efficient for insurers to pay for a pill in a 15-minute office visit,” Twillman said, “instead of a pill, plus a psychologist, plus a chiropractor, plus acupuncture, plus yoga and massage.”

Slowly though, that’s changing, in large part because of the opioid crisis.

The Food and Drug Administration just changed its provider education guidelines to urge doctors to learn about alternative strategies for managing pain.

Some insurers are open to new approaches, too. Oregon’s Medicaid system, for instance, recently began covering more physical therapy and chiropractor visits for people with back pain, so as to help them avoid painkillers and surgery. Cigna, too, has increased its coverage for back pain physical therapy.

Veterans Affairs, meanwhile, is taking steps to reach out early to chronic pain patients, often through their primary care physicians, to coax them into increasing physical activity, sitting through cognitive behavior therapy, and meditating.

Sperry has appealed to Congress to accelerate the shift with more funding — not just for chronic pain and addiction treatment, but also for medical education. She conducts a workshop at Mayo Clinic to teach medical students how to say no to patients who ask for opioid refills — and how to help them instead train their brains to manage their chronic pain.

“We need a cultural shift,” Sperry said. “There’s an implication that there’s a pill for everything — and that’s not accurate. It’s very dangerous.”

First of all, I am glad that this person was able to eventually control his pain without opioids. That is wonderful. I don’t blame him for sharing his story; as I am sure that some are helped by it.

Whether it was the goal or not however, there is indeed a tone here that dismisses opioids for chronic pain as the wrong answer across the board, and that we all should be able to meditate and “think” our way to feeling better. This is not knocking other management strategies: meditation, psychotherapy, chiropractic care, massage, and other non-drug therapies. For some, these (or a combination thereof) can be sufficient for managing pain. More often, they can function as complementary therapies that may reduce reliance on opioids and other medications. It would indeed be nice if insurers offered coverage for such things; in addition to medications, surgery, and other interventions. I too find it problematic that opioids are readily covered—they should be, but not at the exclusion of alternatives.

I am not even saying that opioids are appropriate for all pain. They should be; and usually are, a last resort after other less risky options have been exhausted. However, what I DO have a problem with is the newly in vogue assumption that long-term use of opioids is always bad medicine, that people are dropping like flies from overdose as a result of having their pain treated with them, and that opioids are never useful in the context of chronic pain. The statistics do not support those assumptions as much as many believe.

I certainly have a problem with the now constant implication (or even outright assertion) that those of us who say we are helped by our pain medications; and cry foul at the new CDC guidelines and resulting fallout, are morally degenerate addicts who are in denial and don’t think enough happy thoughts. I am including a link below to something I previously wrote that provides more in depth discussion of the very problematic nature of such assertions. To those who would say that we chronic pain sufferers are overly “defensive” regarding these issues, my answer is “Well of course we are!”

You would be too if you were on a treatment for a chronic condition—one which had literally made life worth living again, and people suddenly decided that your experience didn’t matter and threatened to block your access to it. Just imagine—here you had followed every rule and jumped through every hoop placed in front of you in order to receive your treatment, and all of a sudden you face it being taken away; not because you personally had done anything wrong, but because a bunch of other people misused that treatment (most not even with a prescription), and you were left to pay the price…to live every single day in pain that most anyone would find unbearable, and you now have to wonder whether life would be worth living without access to that treatment. I don’t think there is any question that you too would be pretty upset…terrified in fact.

If we were talking about anti-depressants or medication for ADHD here, everyone would be up in arms, and rightly so. People say that opioids are bad because they cause withdrawal if you stop taking them (some even say that going through withdrawal is itself indicative of addiction…it isn’t, by the way. Addiction is a psychological pathology where someone engages in a harmful behavior—including the consumption of a given substance, despite overwhelming social and/or physical harm and which the person has no independent control over. Withdrawal symptoms that appear upon sudden discontinuation of a medication simply reflects that the body and nervous system have adapted to having the medication present—something the body eventually adapts to not having present after a similar period of adjustment). People also imply that opioids should not be given chronically due to the fact they can be misused for purposes outside their original intent; ie, recreational usage.

Consider though that anti-depressants can also not be stopped “cold turkey,” and that doing so also causes symptoms of withdrawal. Stimulants such as Ritalin that are used for ADHD will also cause withdrawal symptoms if stopped suddenly. Therefore; just as with opioids, it is recommended that antidepressants and ADHD meds be tapered to prevent severe withdrawal symptoms. As far as improper use, ADHD stimulant medications are also frequently misused (ie recreationally, or otherwise not as prescribed); maybe even more so than legitimately prescribed opioids. Nevertheless; as I said, there would certainly be an outcry by the public and medical community if access to these medications was limited in the way opioids are increasingly being limited (even in the case of long term chronic pain patients) right now.

We would consider it unthinkable to expect patients (especially those taking these Prozac or Ritalin for years without any personal issues regarding inappropriate consumption) to live without these medications simply based upon these factors. Understand too that there are even people out there (including medical professionals) who believe antidepressants and ADHD medications are over prescribed. There probably are even many cases where alternatives exist. Sometimes it also comes down to money—insurance would rather pay for a pill than for therapy to help people to better manage their depression or attention issues. A combination approach including medication and aforementioned complementary therapies would probably be most helpful. All of these things can be said for opioids and the more socially acceptable antidepressants and ADHD medications. Yet, they are treated completely differently.

Many in the public and in the medical community would oppose limiting access to meds for depression and attention deficit disorders. Many would even call such a measure cruel. So we must ask ourselves—why should it be any different for opioids? Moreover, is this stigma and limiting access to opioids really helping addicts or saving lives? Finally; shouldn’t doctors; based on their personal knowledge of patients they treat (and have often done so for years) and their professional judgement be able to prescribe the treatment they deem best without constant fear of being targeted by the DEA for doing so (assuming they have a bona fide doctor/patient relationship and documented rationale for such treatment)?

First of all you all need to relax and listen to what MY BROTHER is saying….First of all NO he doesn’t know your pain or what each of you are going through…he is sharing his story with you so that he can try to get you to try to understand that there are other ways of dealing with your pain other then DRUGS!!! IF YOU WOULD READ YOU WOULD KNOW HE DOESN’T KNOW ANY OF YOU AND IS TRYING TO SAVE YOUR LIFE BY MAYBE TRYING SOMETHING DIFFERENT…THAT IS ALL!!He doesn’t claim to remotely know any of you or understand you different situations. Don’t EVER attack a person for what they have gone through and what works for them! Please by all means people stay addicted to your drugs and have a nice life! DON’T YOU EVER ATTACK MY BROTHER!!!

I agree with you. No one can dictate that everyone should be taking drugs for pain. Also, according to a brand new (2019) meta-analysis of randomised controlled trials, mindfulness can be quite effective for pain. Check out the article titled “Mindfulness Could Be a Powerful Painkiller” published in “Psychology Today” (written by Dr. Danny Penman).

Once again appears those who think they have the right to decide for other adults what medical treatment works for them,their delusional ideations have returned to their minds.I hate to put truth/fact into the pictures,,but NO,, no-one has ever stopped true physical pain w/a thought KDN,, and Ms.White,,,again,,,if truth is interpreted as ,”beating up on your brother,” sorry,,but humanbeings are being tortured to death,,literally now a days from opiatephobs,,,who’s arrogance and delusion has literally got them thinking they have the right to decide for medically ill human beings in factual physical pain from their medical condition,how much FORCED PHYSICAL PAIN, THEY ARE TO FORCIBLE ENDURE VIA DENIAL OF ACCESS TO EFFECTIVE MEDICINE TO LESSEN PHYSICL PAIN,,,EVERY SINGLE CHRONIC PHYSICAL PAIN PERSON I KNOW,,HAS ALREADY TRIED IT ALL,, and thee only medicine that worked effectively to lessen physical pain were opiates,,,thats just tough,,if u don’t like it,,not your place to decide for adult human beings how much torture to force upon them,,What,,, do we live in Nazi germany again??Again,,truth as thee guide here,,,it I physically impossible for anyone to physically feel the physical pain of another,,literally impossible,,thus as a humane civilized society,,we seek to lessen that physical pain,,not force it upon a medically ill person,,but to lessen that physical pain,,by what-ever means is effective for tht medically ill person in physical pain from their MEDICAL illness,,,You know,,,physical illness usually is shown,,on a x-ray,,mri,,bloodwork etc,,,thus ie MEDICAL,, now u take the word addiction,,,,can u show me on the human body,,,exactly where addiction is??No,,,,its a opinion,,,a label put their by a humanbeing who has a financial interest in labelling on a part of the brain,,not by any factual physical evidence,,,So I gotta really ask myself,,since addiction is a label,,,just like prejudice,,bigotry,,are labels,,,Why do both of u think u have the right to decide for another adult human being,,,how much FORCED physical pain,,ie torture,,another humanbeing is to forcible endure??Cause right now,,I see it as a arrogance with-in all of u,,,who think u have the right to decide who gets literally tortured today and who does not via denial of access to effective medicines to effectively lessen physical pain from a medical condition..I see it as a bigotry to label a adult a ,”addict,” because you all hate the medicine opiates,,for some bias reason,,some prejudicial reason,,after-all,,addiction is a label based upon a opinion,,,maryw

U know in this age of technology,,,until these propagandist research conclusions are actually video taped from start to finish,,,I will not believe ANY data,research etc other then a propaganda tool for them to deny us access to effective medical care to EFFECTIVELLY lesson physical pain.After all if they have nothing to hide,,,they should welcome there little research studies being video’s 24/7 from start to finish to prove no bias,prejudice or any influence to corrupt their data/research study,,,,right??After all its only thru truth does true knowledge get obtained,,,maryw

Verne what the CDC , the charlatans at P.R.O.P. & doctors are doing to CP patients is cruel and torturous. Please don’t allow them to win by making a decision that many others are making and have made.
I know how horrendous it must be for you.
I am also a chronic pain patient in MA. If you need someone to vent to please get in touch with me via Twitter DM.
cigarbabe2 @ twitter.

What about stem cell therapy, Science pretty much had the cure for arthritis but government continues to do the wrong thing by turning people with pain into drug dependence And this all could have been avoided. What a shame. So stupid and insensitive to our fellow man Does anyone have logic anymore?

TO KDN; Again,,unless anyone can physically feel the physical pain of another,,which is factually impossible,,thus a reality of truth,,Then no-one has the right to tell ANYONE how they should deal w/their physical pain,,For the reality is,,by forcing anyone to forcible endure the physical pain from a medical condition ,u are literally committing thee act of aTORTURE,, and should the poor soul who is forcible being torture by someones opinion/theory,and not factually truth,,, be forced to use death as their only means of stopping said physical pain from a painful medical condition,cause YOU,wanted to experiment w/your opinion/theory,,,then your guilty of torturing another human to death,ie murder,,get enough people to use death to stop their physical pain because of YOUR OIPINOIN,, then its called genocide,,But the elephant into room is,,why,,would anyone put out a article that ,”mindfulness,” lessen physical pain when the reality is,tis truth ,,no-one can physically feel the physical pain of another,,UNLESS,,,,UNLESS,, these authors think they have the right to decide for all of mankind,how much FORCED PHYSICAL PAIN all of mankind should forcible endure.If that’s the case,we might as well start studying Adolf Hitler opinions,for he too thought he had the god given right to decide for all of Germany,and Jewish people,,,who should literally be tortured to death as well,,for he tooo truly thought he had the right to decide,who lived,who dies,who he tortured and who he tortured to death??KDN,,,,DO U TOO THINK U HAVE THAT RIGHT??TO TORTURE A HUMAN BEING BY DENYING THEM EFFECTIVE ,,,EFFECTIVE,,,PROVEN MEDICINE ,,,TO LESSEN PHYSICAL PAIN???I gotta ask u that for what do u think is happening to the poor soul in forced physical pain whilst u test your theory/opinion,,that mindful people feel less pain??If u don’t know what happens whilst u test your opinion/theory,,their being FORCED to endure the physical pain u are refusing to acknowledge as painful,,thats TORTURE!!!!maryw

Hi,
Good information.There are some Conferences happening in which medical specialty would be Pain Management and here is one of those conferences.

2019 UVA Anesthesiology Point-of-Care (PoCUS) Course is organized by University of Virginia (UVA) and will be held from Jan 23 – 24, 2019 at The Village at Breckenridge, Breckenridge, Colorado, United States of America.

So we can save money and fire all anesthesiologists by simply telling people to stop thinking of their pain during and after surgery since all this pain is simply in their heads. This would save billions in medical costs if we can treat pain as something that is in someone’s head and to eliminate the pain they just need to change their thinking. It sounds too good to be true.

In the old days ,,,it was called QUACKERY,,,,,,no-one has ever stopped physical pain w/ a thought,,,,ever,,Lets see this guy do a surgery w/no medicine,,its called saving money no-matter who they torture,,,maryw